Monthly Archives: February 2017

Truly excellent, really well funded Public Schools are the answer to many of our problems and especially so in the United States. But, despite that, the US Congress has proposed a new bill ( HR 610) that will gut their educational system.

Some years ago a book of essays by Robert Fulghum was published with the title “All I really need to know I learned in kindergarten”. Hold hands when you cross the street. Share, be kind to one another, clean up after yourself…. It is cute and fanciful but beneath the smile of recognition there lies a profound truth.

Schools have two jobs. Educating our children may actually be secondary to socializing our children. Originally I suppose, as some sociologists point out, the goal of our newly invented schools was to prepare our children for the factory jobs generated by the industrial revolution. Show up on time, do as you are told, work all day until the Bell rings.

Many years have passed. Our schools have gone through many evolutions keeping up with the changing needs (and fads) of the times. The curricula have changed, and many of the social rules have changed, each accompanied by much dissent and discord.

But I would argue that as our cultures have become so diverse and complex, as our populations become less and less homogeneous, and as future employment becomes both less certain and more multifarious, the role of socializing our children in good public schools becomes more important. Dramatically more important.

Every kid should be sitting in a classroom, playing in the school yard, singing in the choir with at least 50 percent of the other kids being, well, different. Our children need to work with, and play with kids unlike themselves during those 12 or so formative years. Smart kids, not so smart kids, shy kids, obnoxious kids, athletic kids and handicapped kids, black, brown,yellow, white kids, poor kids and not so poor kids, kids with two parents and kids with one, kids who speak other languages, take different religious holidays, wear some different clothing.

There has of late been a rise in “hate crimes” and racial vandalism.

In a way hate crimes and racism are pernicious extremes of tribalism, and they rise in frequency when tribalism grows and especially when our leaders fan the embers.

I think to combat this we must first accept the fact that tribalism is in our genes. We are programmed to notice if someone is not of our tribe. It would be a very important trait in our prehistoric period. Science tells us that when we encounter a stranger, we first notice his dress, and then we notice his tribal markings (think hair/tatoos/metal piercings), then we pay attention to language and voice, and lastly skin colour (when we primates first developed these perceptual skills, we were likely all the same colour).

Our sense of tribe can expand, and one day might include all who live on our earth. A large swath of the white American tribe recently accepted a black man and elevated him to their highest office. Though clearly there were many who never accepted him as one of them.

Still more recently we have seen how easily tribalism can be provoked and inflamed. Brexit, Marine le Pen, Trump. We can struggle against this, we can do our best to fight this trend, but the long term solution is having every one of our children attend, from JK to 12, a well funded Public School, and a school with the complete mix of kids I mentioned before. I would allow home schooling only if, for health reasons, attendance was not possible.

I suppose I would not oppose a small number of private schools because to do so would limit some important freedoms.

I think we already see in some idealistic young people who have grown up in very diverse and inclusive schools a sense of tribalism expanded to include the whole world.

Americans especially: Do not undermine your public school system. Fund it, grow it, improve it. There in lies the hope for your future.

Donald Trump’s reference to Sweden at his rally in Florida has been met with much astonishment and satire. He has tried to explain that he meant to reference more of a trend of refugee crime in Sweden than a single recent event. His supporters repeat this. His detractors roll their eyes.

But what he actually said and how he said it and the manner in which he absorbed the source material are, as usual, very telling. They speak to his attention span, how he is influenced, how he formulates thoughts, his limited vocabulary, and the superficiality of his cognitive processes. Here is his statement: “..you look at what’s happening last night in Sweden. Sweden, who would believe this? Sweden. They took in large numbers. They’re having problems like they never thought possible.”

The source of this remark is a Fox News report he watched the night before. Hence the “last night”. His thinking process collapses the time he watched the report and the time of supposed “events.” The television screen that he watched was split screen. On the viewer’s left a talking head reports an immigrant inspired crime wave in Sweden. This information was apparently gleaned from particular face book rants. But on the right half of the screen we watch videos of unidentified violence and crime: fires, vandalism, assault, riots.

The spoken information is not sourced from government data or first hand reporting but from Facebook tirades and a filmmaker with an agenda. The visual information (always more potent than words as we know) is of unknown origin and time frame.

This makes an impression on Donald Trump. He says, “You look at what’s happening…who would believe this?” So he has not taken in words and images and formulated and judged them, thought about them, considered them, reflected on their meaning – no, instead he simply excitedly points to them, “You look…”

“They took in large numbers.” He conjures an image of swarms of refugees rather than any considered look at numbers, programs, origins, and the problems of integration and settling.

And then, using a kind of vague hyperbole, “They’re having problems like they never thought possible.”

Trump frequently falls back on these kinds of qualifiers and exaggerations. They create an emotional impression without any kind of actual description, identification, or assessment. His favorites are: “You wouldn’t believe.” “Unbelievable” “Like they never thought possible.” “Like you never thought possible.”

Of course I may be wrong. Such speech patterns may not reflect the patterns of his thought; they may not indicate he has the cognitive processes of an excited 14 year old. Perhaps it is an act, a ploy, a strategy. Perhaps in private he can think and talk as a responsible adult.

Open letter to all the sane and sensible Republican lawmakers who wish to see their children and grandchildren grow up in a safe world.

It is time to huddle with sane and sensible Democrats and figure out how to remove Donald Trump from office. Perhaps you are doing that already. God speed.

Thursday this past week, for almost 90 minutes, Donald Trump gave us what has been called “vintage Trump.”

And in that almost 90 minutes, once again, Mr. Trump demonstrated that you have elected for your president a man who is:

A world-class narcissist

A man with a very short attention span (unless he is the subject of praise, and adulation)

A careless liar. A very careless liar. “You look at what’s happening last night in Sweden.”

A man with a teenager’s vocabulary and the conceptual abilities of a 14 year old.

A man for whom everything (and I mean everything) is about his own greatness.

A man with very poor impulse control.

A man with a level of knowledge of the world equivalent to that of a bright 12 year old from a good public school: “I’ve been briefed…and I can tell you one thing about a briefing that we’re allowed to say …because anybody who ever read the most basic book can say it…nuclear holocaust would be like no other.”

A man with no sense of the complexities (and safeguards) of governance in a democratic system. “The FAKE NEWS media (failing @nytimes, @NBCNews, @ABC, @CBS, @CNN) is not my enemy, it is the enemy of the American People!”

A man who, strikingly, does not notice, does not seem to understand or care about, the meaning and inferences of his own words. “You will never meet a person less anti-Semitic (less racist) than I am.” “I’m not calling it fake news anymore, I’m calling it very fake news.”

A man who always blames others, who cannot take responsibility for any failures or mistakes or even oversights. “I was given that information. I don’t know. I was just given it. We had a very, very big margin.”

A man still obsessing about the woman (Hillary) who almost beat him, and the black man more loved than he.

A man who lives for adulation, excitement, winning, not working, not actually doing a job. Hence the constant replay of the November election, and the reprise in Florida last Saturday evening.

Dr. Francis rightly points out that we should not diagnose from a distance, and that a criterion for the diagnosis of narcissistic personality disorder is that the patient be suffering, not merely wreaking havoc on others.

On the other hand, Typhoid Mary was healthy, yet few would disagree with removing her from the kitchen.

And we have lately seen glimmers of the rage within, the rage that will be unleashed when he is cornered, trapped, and finally undone.

Please read my manual for undermining democracy and note the progress to date.

I have had many patients over the years (50 years now, actually) who have done well with treatment, who recover, who have insight, who promise to stay on their medication. They are good people. I like them. We become friends. With some it can involve an ongoing dialogue about needing or not needing to stay on medication.

But at some point most of them stop their medication, at least once. Their lives have changed. They have been well for 20 years. They meet a family doc who doesn’t understand why they are still taking Olanzapine. They fall in love. They move. They get ill in some other way. The pharmacy changes hands. Their doctor moves. They come under the influence of one of any number of cults, including Scientology. They read the bullshit of the anti-psychiatry crowd, or the homeopaths. Someone offers them cocaine.

So at some point most of them stop their medication at least once.

With psychotic illness the illness returns, and it always returns in the same way. With some my relationship is good enough that I can cajole them into going back on their medication. With some I have had to spend hours offering it while my patient tries to decide if I am a friend or the devil. With others it means a complete relapse and re-hospitalization.

And in most cases, the only ones hurt by this relapse are my patient and his or her family. That is no small thing though. The social, emotional, vocational, educational, and sense- of-self cost is huge. Often a year or more of progress is lost.

Lack of insight may be a good predictor of human behaviour, but insight itself is not. An equally poor predictor of future behaviour is remorse, or a display of remorse. “Good behaviour, model patient or prisoner” has also little to do with what will happen in a different context five years from now. I will agree, however, that a good support system is a good predictor, but we need that support system in place for 40 years.

We clinicians are further hampered by our natural empathy, our natural sympathy that flows toward anyone nearby. It is not special; it is just human. At least twice a week during commercials I see on the television screen an emaciated fly-covered child. I get up and refill my glass. But should that child and his mother be in the room with me, my response would be quite different. Hence, as I have seen many times with CCRB cases over the years, the staff actually caring for and treating the patient are very poor at predicting future behaviour.

Now, I have not examined Mr. Li. It is possible he had a psychotic episode that will never reoccur. In my 50 years experience I know this to be only possible if the initial psychosis was caused by a brain injury, a stroke, toxic substances, or withdrawal from toxic substances, or very severe acute trauma within the time-frame of the psychosis. But from what I have read Mr. Li developed a schizophrenic illness with hallucinations and the specific delusion that resulted in a very specific horrendous crime.

So, from my 50 years of experience, I would say the people who know Mr. Li, who have spent time with him, are the last people who should be making predictions of future behaviour. Secondly, insight, remorse, promises, even absolute statements of conviction are not good predictors of distant future behaviour.

We know this man, when well, is a very nice man, and could be a good citizen of any community. We also know when ill he is capable of committing a horrendous crime.

Would it not be reasonable to use the tools we have to keep him well for the next 40 plus years? To protect Mr. Li and any future community in which he resides? They are not overly constrictive or intrusive considering the possible consequences of a relapse.

By allowing even a remote chance of a repeated homicide by Mr. Li you are doing everyone else diagnosed with a psychotic illness a great disservice.

Vince Li has been treated now, for his schizophrenia, for 8 years. He has been living in the community and attending classes. The Review Board has given him an “absolute discharge”. He is, we are told, recovered, insightful, remorseful, and willing to take his medication regularly. Thus he is not a threat and qualified for absolute discharge.

He may well remain healthy and compliant with his medication for the rest of his life.

Perhaps the odds are slight that he will stop his medication and become ill again.

But, here are two realities about psychotic illnesses, schizophrenia in particular:It is hard to catch a relapse.

When a patient stops his medication he will feel fine for a while. And when the relapse begins the first thing to become impaired is insight. One can monitor mood, but not one’s own cognitive processes. So very few people with schizophrenia who stop medication and feel good for a while, are then able to detect, on their own, the early signs of cognitive changes. As the illness worsens the prospect of insight lessens. It is the nature of schizophrenia. It affects thinking.

When relapses of psychotic illnesses occur, the original delusion returns, if not exactly word for word, almost word for word. Thus if the original delusion was relatively harmless, in a relapse the patient’s returning delusion will be relatively harmless. “They are listening to my thoughts from the TV so I don’t ever turn it on.” “It is happening again.” But if the original delusion was dangerous: “I must kill to rid the world of the devil”, then when the relapse occurs the person in question will once again become dangerous.

Thus, even if the possibility of a relapse of illness for Mr. Li is small, such a relapse would be far more dangerous than for most people with this illness.

And if this occurs, if Mr. Li relapses and hurts or kills someone else, the cost will be much wider than Mr. Li and his victim. “Let’s talk about it” will certainly not be enough to reduce stigma then.

Such an occurrence will undermine the compassion and civility of the “not criminally responsible” finding.

The average citizen has trouble buying this defense now, for various reasons, especially when the crime is horrifying. If Mr. Li relapses and commits a crime, the community outcry will be very strong. A relapse and repeat by Mr. Li could thus do great harm to all mentally ill in Canada.

This could have been remedied simply: a discharge (though not absolute) that continued a lifetime of monitoring compliance with treatment. Not overly intrusive or restrictive. Simply making sure that Mr. Li continues his treatment, that he continue to take his pills every day or his injections every two weeks.

If Mr. Li stops taking his anti-psychotic medication, one year or ten years from now, the illness will relapse. And the delusions of this illness always return in the same form.

I have been watching too much CNN. I must control this new addiction. It is bad enough to find oneself compelled to watch a train wreck or a car accident, to have to slow down and gawk, but now I’m following the ambulances into the ER and waiting to hear the pronouncements of the doctors and nurses and next of kin.

Each evening several panels comprised of both political persuasions dissect the president’s tweets and statements, seeking substance, direction, and meaning, seeking precedent for his personal attacks, sometimes deftly skipping past his actual words to re-frame and reword the proclamation in question. They are often concerned about the political advantage or disadvantage his words might have. As George Orwell and Mark Twain and others have told us, when the outrageous lie becomes commonplace it loses its ability to outrage us. It becomes “strong opinion”. It may even become “alternative fact”.

But none of these panelists seem to pay attention to a part of Donald Trump’s speech that I think they should. Perhaps they need a linguist on one of their panels. Like a child
Trump calls the judge a “so-called judge”; like an envious teenager he revels in the low ratings of Arnold Schwartzenegger; he demonstrates every day he has no boundaries, personal, professional, or ethical.

But this is the kind of sentence I find most frightening:

“I comprehend very well, better than I think almost anybody.”

Without irony or a wink he begins to tell us that he comprehends better than anybody, that he is smarter than everybody else. Then as he is forming the words he catches a glimpse of how this will sound to others, and he squeezes in the phrase, “I think almost”.

He did the same when he said, “I am very smart.” He squeezed in the word “like” to soften the statement a tad, even if it ended up sounding adolescent.

I can analyze this as a grandiosity that is really an over-compensation for insecurity, but it is, nonetheless, grandiosity: A belief in his own powers, in this case his intellectual powers, that far exceeds reality.

As President Kirkman said last season: “There is nothing more dangerous than a pawn that thinks it’s a queen.”

It is this grandiosity that will bring down the house, or some day implode in rage.

I had a friendly argument with a colleague the other day. He reminded me that we had been arguing about this topic for 40 years. I think our arguments are mostly ways of clarifying our own thoughts about a very complicated question involving concepts of mind, of cognition, and of the brain, that organ who’s function makes us human.

Mental illness, disease, disorder, serious mental illness, continuum, spectrum, problem, affliction – when is it both valid and useful to consider aberrations (or non-typical) variations in behaviour and thought, illnesses? In some ways these words are just words, and few would care if we referred to arthritis in any of these terms. But when it comes to behavior, thought, and communication (rather than joint flexibility and joint pain) our dearly held beliefs about self, autonomy, will, power, consciousness, and mortality come into play. The discussion becomes political.

Before the medical disease concept evolved in the 18th and 19th century most afflictions were considered very personal and specific, and the causes very personal and specific. An obvious grouping of afflictions might mean God was particularly disappointed in a whole family or tribe. The Miasmists thought that perhaps God did not have that much control over everything and proposed that the causes might be found in the atmosphere, the miasma, physical, spiritual, emotional. An excess or a deficit. The Naturopaths liked this idea but knowing nothing of physiology, metabolism, or nutrition, concocted potions and powders with dozens of ingredients positing that the body might choose from the lot that which it needed. Each of these ideas continues to echo in the pursuit of health today. Especially in the commercial exploitation of our pursuit of health.

The disease model is founded on the idea that if a number of people suffer the same symptoms and signs, and if their affliction follows the same course with the same outcome then perhaps these people suffer from the same “thing”. This in turn raises the possibility that the cause is the same in all cases and that a treatment that works for one will work for the others. To study this we need to name (diagnose) the thing and describe it’s symptoms, signs, and natural course. Given that we are biological beings it is reasonable to think that some of the signs of these diseases will be biological, and that the causes might be as well. But first the chore is to observe, study, collate, find groupings and test this hypothesis.

In a sense the disease model has picked off all the low hanging fruit, those illnesses with very specific causes and courses and, of course, those for which we have found specific treatments, cures and prevention.

The disease model, and some rudimentary epidemiology, led Dr. John Snow to the source of an outbreak of cholera and then to speculate that the cause, residing in the water supply, “behaved as if it were a living organism”. This before we knew about bacteria, let alone viruses, prions, DNA, and neurohomones.

The same disease model has led to the near eradication of Polio. Drs. Alzheimer and Kraeplin applied the disease model to older people with failing cognitive processes and singled out an illness we now call Alzheimers. Dr. Alzheimer had the advantage of being able to examine the brains of his patients soon after diagnosis. Dr. Kraeplin went on to apply the disease model to a younger group of patients with peculiar cognitive difficulties, some similar to dementia, some not, and singled out a group he called dementia praecox, and another group he called manic depressive. Similarly and more recently the disease model singled out autism from the broader group of mentally handicapped children.

The disease model also allows us to study afflictions and find remedies before, sometimes long before we establish with certainty the causes of the affliction. Who on earth but a cruel idealogue would want us to stop treating and reducing suffering until we find an exact and specific cause of the affliction in question, be it cancer, arthritis, or schizophrenia. Yet that is the cant of the anti-psychiatry folks.

Yet the disease model allows us, sometimes by accident, to find remedies that work, can be proven to work, before we nail down etiology. Now, as mentioned earlier, the disease model has picked off the low hanging fruit, those afflictions caused by single alien organisms, and very specific genetic aberrations. We are left with those that are undoubtedly the product of complex combinations of genetic vulnerability, epigenetic influences in the womb, environmental influences, developmental timing, excesses, and deficits.

But we should no more give up on the disease model for schizophrenia and depression than for heart disease, cancer, arthritis, ALS, and dementia.

Our argument was actually about OCD. Having some Obsessive and Compulsive traits can be an asset of course, and of great help in medical school, while extreme OC traits can be debilitating. The “D” of OCD is the initial for “disorder” of course, but is OCD, in annoying to debilitating form, a disease?

Unfortunately the word “disease” has become freighted with negative association, and for my friend, too much associated with “biological cause”.

Ultimately he may think of OCD as a mind problem, while I may think of it as a mind/brain problem, but it is the discipline of the medical disease concept that allows us to study it and find remedies we can test.

We talk about him incessantly. We worry; we laugh; we snicker, we cry. Every day we see his narcissism on display. Everyday we see him manipulated by a handful of petty tyrants. Everyday he displays his ignorance anew. Everyday we get to see his carelessness.

And I start to wonder. When did it become too late to stop Hitler? When did it become too late to stop the First World War? When did it become too late to stop Franco, Mussolini, Stalin, Idi Amin, Pol Pot? When did it become too late to stop the Great Depression, the war in Iraq, the rise of ISIS?

Things are moving quickly my American friends. Please get together, form a coalition, if necessary put your political careers at risk, but start your filibusters, begin the impeachment process now.

I don’t want my grandchildren living on a broken planet wondering when it became too late to stop Donald Trump and Mr. Bannon.

Every country in the world has a few young men capable of committing a mass murder. They are angry; they blame others for their failures; they nurse grudges; they are easily caught up in conspiracies; they rebel against any authority; they lap up the hatred of others; they spend much of their time lamenting about the state of the world while drinking beer or snorting cocaine late into the night; they are unsuccessful with women. They deeply fear the world of adult responsibility. They play first person shooter video games. They like guns. They harbor racist grievances. Some are “loners” as the newspaper will call them, but this usually means a mental disorder that limits their ability to engage face to face with others, and allows them to build a delusional world view from other sources. Of course the impersonal sources from which they can build that distorted world view, and their place in it, has dramatically increased in the last 20 years.

But usually these young men hurt few but themselves and their families. They don’t (usually) act upon their darkest fantasies.

Unless they are given license to do so by someone with a loud voice. That would be you Mr. Trump. Your careless words, your disdain can unleash such horrors no matter that it was not your intention.

When I write my blogs about American politics my daughter reminds me I am Canadian. But we breathe the same air; your messages are clearly heard north of the 49th parallel. It is a sad thing the first young man who took your words and actions as license to kill was a Canadian. I trust our response to this will continue to be very Canadian.

But beware, Mr. Trump, you and Mr. Bannon have the capacity to unleash the contemporary equivalent of Krystallnacht.